| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,435 |
1,432 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
2,737 |
2,728 |
$138K |
| D1120 |
Prophylaxis - child |
2,757 |
2,752 |
$95K |
| D1110 |
Prophylaxis - adult |
985 |
978 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,276 |
1,276 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,634 |
2,623 |
$55K |
| D2140 |
|
815 |
511 |
$44K |
| D2160 |
|
547 |
415 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,810 |
3,802 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,246 |
2,243 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
286 |
286 |
$13K |
| D1351 |
Sealant - per tooth |
446 |
158 |
$9K |
| D0350 |
|
986 |
574 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$7K |
| D0272 |
Bitewings - two radiographic images |
436 |
436 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
64 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
270 |
$3K |
| D2330 |
|
23 |
13 |
$2K |
| D2954 |
|
15 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$664.00 |